Speaker1: [00:00:00] You can't design governance and theory in the absence of reality. Clearly, the NHS by itself has very little power to make any difference. We need to pay them more than Tesco pay people to stack shelves because it's a hard job. Well, the local authorities were saying to me "it's all very nice, but what's it got to do with us?" It's not economically viable.

Speaker2: [00:00:21] Voices of Care. The healthcare podcast.

Speaker3: [00:00:24] Rima. Welcome to Voice of Care. Thank you for giving us your time today.

Speaker1: [00:00:27] Well, thank you. I'm very excited to talk to you today.

Speaker3: [00:00:29] It's a pleasure. It's a dramatic year, 2024, the Darzi Review, Mr. Streeting's missions and etc. And I think at the centre of it, integrated care boards are very much at the epicentre. You've been at the helm there for four-odd years. I wonder if before we go into the detail, just to give us a bit of a flavour of the population you serve? It's quite a diverse and growing population, from what I understand.

Speaker1: [00:00:57] It is, it covers Bedford Borough, Central Bedfordshire, Luton, and Milton Keynes. So four different local authorities, something like seven, eight different NHS providers, over 4000 voluntary sector providers so vast the population itself is over a million people. But as you say, it's very rapidly growing. It sits between Oxford, Cambridge, and London, but housing is cheaper so people like moving to the patch. You have a mixture of urban and rural, but we're growing at about two and a half times the national average, and the population will have grown 25% by 2043, and that is a lot for the local infrastructure to cope with. We have big areas of deprivation, as in Luton, where the council has the ambition of eradicating poverty by 2040. And then you have just next door the much more affluent Central Bedfordshire, which is also a lot more rural with lots of market towns, but it also has pockets of deprivation and lots of different nationalities across our patch.

Speaker3: [00:02:05] Hundred languages or something like that.

Speaker1: [00:02:06] At least. Obviously with Luton Airport there, a lot of asylum seekers arrive in Luton Airport and are housed within Luton and a little bit beyond. And that again brings some cultural challenges, some integration challenges.

Speaker3: [00:02:21] And pressures on the system in terms of covering them.

Speaker1: [00:02:23] Definitely pressures on the system, not only the NHS but of course local authorities who are struggling to find enough space to house everybody.

Speaker3: [00:02:31] And just very briefly, your own background, you're a scientist by training. I think you've worked in life science and across the whole gamut. I think you began in life sciences and then NHS as well as social care. I think you've got quite a unique vantage point there.

Speaker1: [00:02:49] That's right. So I have probably done every part of the NHS bar mental health, sort of in a primary care trust. And I was at a strategic health authority. I've been in an acute. I've been on one of the local offices, regional offices of Health Education England, um, and so on and so forth. I've also been on the board of NICE. So I have seen the whole gamut, which of course has equipped me well for this particular role. In social care, I was on Anchor Trust, which looks after the elderly, and I currently chair Sue Ryder, which is one of the two national providers for palliative and end-of-life care.

Speaker3: [00:03:26] So an amazing vantage point, which is going to carry the burden of the fact that I'm going to say that gives you a full view of what's going on. If we can just look at the national picture briefly, I've talked about obviously the Darzi review that came out in September. But it's also a couple of years now since the Health and Care Act and the statutory footing for integrated care systems and care boards. What's your view? I mean, you've been in post for four and a half years. Just a snapshot of the national picture. You see so many parts of the system. We've got the promise of the integrated care systems.. was very high. And reports show that actually there's been some interesting work nationally across them.

Speaker1: [00:04:09] Absolutely. I think a lot of people don't realise that the systems are much more than just the NHS. It's very much working with social services, with the voluntary sector, and trying to do that shift that we're. Streeting is talking about so much more about trying to keep the population healthy. If they are well, keep them well. If they have chronic conditions, empower them to manage their chronic conditions rather than just trying to get that treadmill working faster in the NHS to treat illness. Because when you look at any one individual, 20% only of their health and wellbeing is determined by their access to healthcare and the quality of their healthcare. The rest of that, 80%, is partly determined by lifestyle behaviours and choices such as smoking or drinking, but it's also access to education, access to employment, access to green spaces, the quality of housing. Clearly, the NHS by itself has very little power to make any difference there, which is why it's so important that we work in partnership with local authorities and others who can help us look after the whole person, and not just sick people.

Speaker3: [00:05:15] We have to, as you say, put it in the context of these wider socioeconomic determinants. I'm going to just briefly touch, given the fact that I have a scientist in front of me. Just briefly,  there's a tremendous amount of literature, conversation, promise around the transformation of personalised preventative medicine, genomics. Are you excited about that? Because that's, again, something that has been highlighted by many commentators.

Speaker1: [00:05:43] I am and I'm not. I am because it is really exciting. I think some terrible statistic, about 80% of drugs only working in 20% of people. Or vice versa. But they're not as effective as you might think. But if you can profile somebody and give them the right drug, that will work for them, that's great. The problem that nobody has yet worked out is that, it's not economically viable to look after smaller populations of patients for industry, for example. So when I was at GSK, it was always a question of how small a population can you look at for it to be economically viable? And even from the NHS perspective, if you now need to do genetic profiling for every patient, given all the other pressures, it's not that I don't think there's a future, there's absolutely a future, but I do think we're ready. And so I think we need to hope that the science doesn't go so far ahead that we can't keep up.

Speaker3: [00:06:39] And the context has to be, of course, one of the statutory requirements for the integrated care systems and boards is to ensure that stays within a relatively constrained budgetary environment so that we drive value for money.

Speaker1: [00:06:53] There is, but there is always the business case. So if you can make someone a lot better so they don't need any more interventions, then it's worth the cost potentially. So you do take that initial investment hit. But if you're not going to make much of a difference and this is obviously something that NICE grapples with, which is how much of a difference, what's that risk-benefit profile of any intervention? And can we make it work? So for example, Hepatitis C, when you look at the vaccination that currently cures people or the drug that cures people, well then you've cured them. So it might be an expensive drug, but you've cured them. So what are you saving in terms of downstream costs if you cure somebody from that particular disease? So yes. It's beyond my pay grade. But it's definitely an economic argument to be had.

Speaker3: [00:07:47] Thank you for that because I think sometimes it can be reported quite simplistically. There's a wonderful treatment, this can solve everything, but actually there's a myriad of factors that have to be baked in from population size, etc. I wanted to dive in, in terms of the work that you've been. I think it's four and a bit years, five years nearly that you've been at the board. You chose your moment really dramatically, I think. You worked remotely when you joined as COVID hit?

Speaker1: [00:08:15] Absolutely. I didn't meet anybody face to face for at least six months, and certainly couldn't travel around the patch to see what was going on. And that was a tricky time. It was obviously two and a bit years before we became legal entities. The system existed, but the relationships between partners weren't as good as they are now, and partly held back by the fact that people couldn't meet face to face. And of course, their attention was torn to looking after the pandemic. So I think it stalled. To be fair, for at least the first year of my being there, but also it required a shift in the conversation to get people to come to the table.

Speaker3: [00:08:58] Now, I want to touch upon that because I'm really keen to hear about your new strategy, the 24/29 Living a longer, healthier life. Fascinating. But before we do that, there's an issue around, you've hinted at it, bringing people to the table, the disparate group who don't historically particularly work closely together across the board. And that requires a cultural shift, some quite courageous leadership. Can you take us through what that journey has been like? Because it's not been a linear process.

Speaker1: [00:09:31] It hasn't been a linear process. It was a very stressful process to start off with. Historically, as you say, people either had no reason to work together or didn't like working together. But importantly, that shift, particularly from in conversation from NHS speak. So the strategy at the time had a chapter on cancer and another on mental health, etc. Well, the local authorities were saying to me, that's all very nice, but what's it got to do with us? And they'd been spending a lot of time discussing and not agreeing on potential theoretical governance of how all this was going to work.

Speaker3: [00:10:09] On a piece of paper.

Speaker1: [00:10:10] On a piece of paper. And clearly that's never going to work. You can't design governance and theory in the absence of reality. So when I came in, I put a stop to all conversations about governance. What I discovered that whilst the leadership was trying to work out the raison d'etre of the ICB, people on the front line were getting on with things and I discovered something like 13 different groups doing some amazing work, from prevention to screening, for example in cancer to getting into the depths of populations that weren't traditionally engaging with their own health or with the institutions such as local authorities and the NHS. And I brought them to the board to talk about the work they were doing, to get the board to understand that it was not really about the individual organisations, it was about the population. And if you put residents, I won't even call them patients since we're trying to keep people well, as well. If you put residents at the heart of the conversation, you start to analyse what's going wrong in people's lives around them, that's making it difficult for them to lead fulfilling and healthy lives. Then everybody could start to see their purpose being around the table.

Speaker3: [00:11:19] So that's drawing on the lived experience, and I guess to some extent, well, not to some extent, a co-production in terms of the strategy that you've created.

Speaker1: [00:11:28] Absolutely. And co-production, we're getting better and better at. It was happening in pockets in some of these pieces of work, but it was really important that, for example, if we take children and young people in their health, if you look at it through an NHS lens, you might talk about maternity services, immunisations, mental health, all of these things that are impacting on children's development. But if you look at that holistic approach, you start to identify the vulnerable families where parents might need some support, the families that are homeless or need to be in better, less mouldy housing, the opportunities to give children insight into careers they didn't realise that were open to them and give them that opportunity to blossom at school and then get work experience and then take on, you know, meaningful jobs later on in life.

Speaker3: [00:12:22] Absolutely. And I think what I found really interesting in looking at the strategy and the genesis of it was there was a there was a shift. It sounds subtle, but I think it probably has quite profound implications is you took the organisation from not focusing on what we can't do, but what we can't afford not to do.

Speaker1: [00:12:41] Yes. I mean, everybody talks about the NHS being broken. I don't know if broken is the right word. It is certainly overworked and not capable of dealing with the ever-growing demand. Therefore, we need to do something about the demand side. And the only way you do something about the demand side is to start to understand why the population is unhealthy and what it needs to get itself back on a better track, because otherwise we've got these long waiting lists where people end up becoming more ill. By the time they're seen, they're very acutely unwell. Whereas if you tackle it much earlier on, you might either prevent them from becoming ill or you're dealing with something much milder and therefore you can correct that course very quickly. And therefore, that's why it's really important that these systems exist, because the NHS can't do the prevention piece and certainly can't do it by itself.

Speaker3: [00:13:31] Now, before we dive into a couple of areas, I'm really interested in primary care and tackling health inequalities. I just want to set the scene or ask you to set the scene. This forward plan 24/29. It didn't come in a vacuum. You talked about all the work that was going on, but it's been deeply informed by the Denny review, and I think that's been recognised in terms of shortlisted for awards, etc.. So I wonder if you can give me that context because I think that's really important. It was data-driven and also experientially informed.

Speaker1: [00:14:06] Absolutely. So, just to explain to people what our plan is about. We defined it in five pillars. And it is intentionally high level because for different demographics in our population, the priorities underneath each of these pillars will be different. But it's intentionally around the population. So we have start well, giving every child a good start to life and living well, which is both the prevention piece and helping people cope with long-term conditions. Ageing well, which is obviously literally those healthy years of life, not just living longer, but actually living it in a good way, and dying well, obviously within the same pillar. Growing the local economy, sustainability. So our roles as anchor institutions, as very big employers in the patch, what can we do? And then the last one you would argue, and it comes to the Denny review, is about health inequalities. You could argue that actually it's a thread that runs throughout all the other ones, but it's so important that we wanted to make sure we weren't forgetting anything. And when you look at health inequalities, there is the gap in life expectancy. There is also a 20-year gap between the most affluent and the least affluent population in terms of the years of healthy life at the end of life.

Speaker3: [00:15:25] That's significant.

Speaker1: [00:15:26] That is very significant. Who wants to live a long time if they're going to be unwell? And the Denny review. So Lloyd Denny is a pastor in Luton. He was actually commissioned by the predecessor, CCG, to go out there and do a really good, solid piece of work that helped us understand those populations that don't engage with us. Why don't they engage with us? What are the barriers that we're putting up that stop them from trusting us, from wanting to engage with their own health? And he started off by doing this big literature review with, I think it was the University of Sheffield, and they looked at what we already knew through the literature. And then over the subsequent two years, they went out and they interviewed all sorts of different populations, so different ethnicities, the Gypsy, Roma, travellers, but also disabled people, LGBTQ+. And we got a very rich report that some of which you can't believe it happens, like the deaf people asked to call up for an appointment, or sending letters to the Gypsy Roma, who quite often can't read, write or even sending letters to people who can read in their language but they can't read their own language.

Speaker3: [00:16:47] Right, okay.

Speaker1: [00:16:49] So basics of communication and access are already a problem. And then on top of that, you have people who are new to the UK who may not understand the way the UK system works, who go to the hospital first because that's what they do back home. So we have a rich amount of information now, and some of these things are quick wins that we can fix quickly, and other things will take time. What we are doing is.. You talked about co-production earlier. This is very much at the heart of what we're doing. So we are currently redesigning our musculoskeletal pathway. The intention being that people can self-refer, which at the moment 15 to 30%...

Speaker3: [00:17:29] Gives them agency.

Speaker1: [00:17:30] It gives them agency. 15 to 30% of calls to GPS are for MSK referrals.

Speaker3: [00:17:34] Okay. That's significant. Yep.

Speaker1: [00:17:35] So therefore you free up the GPs. But people can take that first step and go and see somebody on that pathway. And the way we've been doing it is that co-production piece. So it's taking us quite a long time to do the spec because of that co-production. But by talking to people who've had gone through the pathways, what was good, what wasn't good, where are the gaps? What do we need to improve? We're designing something with them, and we have also trained up residents to work with us to select the eventual successful bidder. And we are not going just to the usual residents who are very happy to come forward. We've engaged with those communities that are not normally asked.

Speaker3: [00:18:21] Whose voices are not heard.

Speaker1: [00:18:21] Exactly.

Speaker3: [00:18:21] Right, right.

Speaker1: [00:18:22] And so hopefully, I mean, the proof will be in the pudding. But hopefully we will design something with them and continue to engage with them as we deliver this new service that will continue to improve over the next ten years and deliver a really beneficial pathway to all residents.

Speaker3: [00:18:40] But looking at primary care and access has been an issue identified. Although the numbers from NHS England published in August '24, showed that GP appointments in the area had grown from the previous year, so there was some great stuff. This was, I think, the April to June period. But I just want to tarry there if we may, talk about mental health, I think... really interesting, using digital to support mental health, the ShinyMind initiative is really fascinating. I've looked at that a little bit. It's moved the dial quite a lot.

Speaker1: [00:19:14] It's moved hugely. So, during the pandemic and post-pandemic, as we know, NHS staff were really struggling with their own mental health and wellbeing. So in coordination with them, with the psychotherapist, with a digital app developer. This app called ShinyMind was developed, and it's used by people who want to use it in conjunction with a little bit of therapy sessions. But it teaches them how to cope with anxiety, with depression, with menopausal symptoms, and at that point with NHS staff, the retention of staff versus those who didn't use this app was phenomenally different, statistically significant, and generally wellbeing, the sense of wellbeing really shot up.

Speaker3: [00:20:00] Workforce, of course, is one of your key enablers under the Forward plan.

Speaker1: [00:20:03] And so a lot of these clinicians were so inspired. And when I say clinicians, I'm including everybody doctors, nurses, allied health professionals. They were so thrilled with this app. They started prescribing it to their patients.

Speaker3: [00:20:16] Okay. Interesting.

Speaker1: [00:20:18] And now we've got some very interesting pilots going on whereby a primary care practice in conjunction with a psychotherapist that designed this app are running digital online consultations, not with one patient. They're trying 100 patients.

Speaker3: [00:20:37] At a time.

Speaker1: [00:20:38] At a time.

Speaker3: [00:20:39] Wow.

Speaker1: [00:20:39] They tried smaller than that, and they've grown the group.

Speaker3: [00:20:42] It's incredible.

Speaker1: [00:20:43] They targeted specific patients and invited them. Had a good response. People joined. They weren't sure how it was going to go as a group session. The data is phenomenal. People really felt better as a consequence, really moved the dial. A lot of them, if they have IApps, now need fewer sessions than they would have had otherwise. And a lot of them, because you get constant push messages to help you cope with your mental health. They are really doing very well. Um, and this would be a great way of tackling those slightly lower-level mental health needs so that rather than people sitting on waiting lists for months and months on end, can now. So now we're looking at how can we roll this out across primary care. And the other challenge I'm giving them is and how can we start to roll it out to teenagers. This is currently being rolled out to people over 18 right. But we know that there are very high levels of anxiety and stress and depression in teenagers.

Speaker3: [00:21:43] Pre-COVID and actually exacerbated post.

Speaker1: [00:21:45] Exactly. And if we can start doing this rolling it out in schools, it's a medium that works well for that generation. We might again be able to start helping teenagers much earlier on and help them then cope and find coping mechanisms for later on in life. So it's very exciting and so far so good. The data is really promising.

Speaker3: [00:22:09] Now, we look forward to getting an update from you in due course. One of the other measures that struck me was the collaboration with local partners to tackle depression. Part of the starting well and living well, and obesity and social isolation. I think with MK Dons, that struck me as being quite an inventive way of actually trying to tackle these quite endemic issues.

Speaker1: [00:22:33] Absolutely. So MK Dons, obviously the local football club to Milton Keynes, they are working with children, often from deprived backgrounds who suffer from anxiety, social anxiety. And because they're suffering social anxiety, they're also suffering from loneliness by engaging with these children and around sport and bringing them into teams. And they are finding that they're having great results with these kids who basically make friends with the others, who are also playing football and giving them a purpose and something to look forward to in the week. And there are many other examples of how VCSE is doing this. And it's very exciting. Slightly differently, the YMCA goes into Milton Keynes Hospital's A&E. They pick up kids who are in there because of gang-related injuries.

Speaker3: [00:23:25] Right. Which is unfortunate.

Speaker1: [00:23:27] Which is an unfortunate thing. But they then work with these children after they're discharged to help them get out of that vicious cycle that a lot of children find themselves in today.

Speaker3: [00:23:38] Absolutely. No, it's very inspiring to hear about that. I wanted to spend the rest of the podcast tackling that very big picture that you painted, quite rightly, around health inequalities, the Denny review. Set that into context. There's quite a lot of literature about ICSs that have now begun. Trusts, sorry, have begun to embed tackling health inequalities. It's such a big topic. I wanted to start with one area, if I may, and then of course we'll widen it. And that's something around what has been termed economic inactivity. So the people who are not searching for work when they're out of work. Often a connection to ill health. I think that's one of the top priorities. And you've been doing quite a lot of work as a system.

Speaker1: [00:24:22] We have, and we've been tackling all sorts of different aspects of employment. So we had a seminar. What we tend to do is we have a very we have the board. I've made it a very big board. It includes all our partners, and we will do a lot of the more corporate business. But in between we have board seminars that we run in conjunction with the Integrated Care Partnership. And to that, we normally focus in on one theme, one topic, and we invite relevant VCSE and police and fire and education depending on what the topic is. So we had one such seminar on employment. And how do we get people who have fallen out of employment due to physical or mental health issues? Either they can't get to the point of taking on a job, or they take on a job and find it hard to stay in the job. And there are lots of fantastic charities out there. I think what we need to remember is it's a very hard time for charities and we can ask them to do more with us, but we've also got to work out how it all fits together so that we can make sure that they are well resourced to deliver. And from that seminar, each of our four places have taken away an action plan to tackle their own population. But as I was saying earlier, that's one aspect of employment. A lot of our children from deprived backgrounds don't have enough role models to show them what other possible careers there are out there. So if you took the NHS alone, there are 350 different roles. Only half of which are clinical. So it was always my mantra that we should give these children work experience and work insight, not just into the health and care, because not everybody wants to do that.

Speaker3: [00:26:07] But they may not even thought about it as a potential career.

Speaker1: [00:26:09] They may not have done, but we've also got finance departments, marketing departments, HR departments, you know, between us, not just in the NHS but local authorities, we've got a lot that we can expose them to, and that's been very successful. So we run career fairs.

Speaker3: [00:26:26] Is that university or school?

Speaker1: [00:26:27] So mainly well, actually both school and university. But obviously by the time they're at university they've already chosen a career path. So we do a lot with the 14 to 18 year olds. We work with the University of Bedfordshire who are doing these outreach programmes where they put on plays in schools that role model different aspects of health and care delivery. And there's some lovely anecdotes that come back where children say, wow, I never even thought about this, but this is actually quite exciting. I think I would like to be a physiotherapist or an occupational therapist or a dentist.

Speaker3: [00:27:04] So they see it brought to life, rather than here's a brochure or a book.

Speaker1: [00:27:07] Exactly. And it's taken to them. And then they sit there and go I didn't know that I could do this. I thought it was someone else. I didn't realise I could aspire to doing this. We've got apprenticeships. We had four of our apprentices actually come to the last board meeting to talk about their experience and how for all of them, it took them onto a different track, whether they were already mature students with families who took a particular track or discovered that they could do this while they were at university, maybe doing a science degree, and then change onto a different course altogether. But it's great because if you train your local population, they also stay local. So in terms of growing your workforce, it's a win-win for everyone.

Speaker3: [00:27:54] And growing the workforce you mentioned is obviously a central pillar in terms of the seminal long-term workforce plan back in June 2023. And I just want to touch on that briefly because you've mentioned the apprenticeship. There's going to be a need, I guess, to re-envision also how the NHS trains people that want to go in whatever pathway, whether it's clinical and non-clinical. And I just wanted to get your view as a scientist and someone with so much experience, what will that require and what will be the role of digital training? Because it offers, it promises so much, but it's not a simple fix.

Speaker1: [00:28:32] It isn't a simple fix. At the end of the day, health and care is a human interaction career. And yes, you can teach the science, but that hands-on experience I don't think you can teach through digital. And the people that we're trying to target may not have access to digital today. They may do. Over time, more and more people have access to digital, but right now that's not feasible. I know the NHS is talking about doing apprenticeships for doctors and I'm really interested. I think that's definitely possible. Why wouldn't you be able to learn and train on the job? You know, you do the classes and then you get a lot of universities. My son actually is about to start medical school. He will be in lecture theatres and in practicals, learning the science. But then he'll be doing placements quite early on. So this is with a bigger emphasis on placements. But there's no reason why you can't train your doctors that way. And I do think that we do need to become more nimble and less rigid in the way that we've been doing our training.

Speaker3: [00:29:34] Absolutely. And finally, if I may, I wanted to look ahead a little bit. We have a promise of a new NHS plan. Dramatic changes. Now, that's a big topic. We could be here for a long time. But with your leadership role in an integrated system, are there 2 or 3 key things that for you you'd like to see the dial turned on that would help facilitate this mission in terms of value? Driving value for money. Improving population health and the small matter of tackling health inequalities.

Speaker1: [00:30:07] Yes, absolutely. I do believe that we need to tackle the demand side. And whilst we continue to focus on acute performance and ambulance handovers, which are very important operational KPIs. But that's only a tiny part of the story. But it does distract leadership attention.

Speaker3: [00:30:25] It takes all the headlines unfortunately.

Speaker1: [00:30:26] And therefore people go well, prevention is great, but we haven't got the time, we haven't got the money. But again, I think we need to redefine financial business cases. Because as I was saying earlier, if you've done prevention, you then don't have the demand. You then lower the costs. But that happens over time. That's not a one-year thing. And everybody, of course, talks about shifting the bulk of the money, I think it's about 60% of the money goes into acute is currently not leaving very much for community health, mental health and primary care and primary care in its widest sense, not just GPs. And therefore how do you do the prevention if you can't do that shift? So a lot of the rules that currently exist in terms of that funding are difficult and difficult to overcome to make those shifts difficult to make that longer-term investment. Doesn't mean you can't do it. We're being quite creative, but it's a shame that we have to be creative, that we've got those barriers. And so that's the first thing. Social care obviously everybody talks about when are we going to fix social care? We're lucky that our four local authorities are doing their utmost to get social services very responsive to the needs of the NHS because it is symbiotic. But they are also constrained and they are also struggling financially. So I think that is also an area where we need to make social care careers really interesting. We need to pay them more than Tesco, pay people to stack shelves because it's a hard job and we need them to have a career path, something that's a bit more aspirational. You know, I could say, or we need more money for capital and all of these things that are in the press, and that is true. But I do think that it's that...

Speaker3: [00:32:09] Re-envisioning of the finances, connecting with social care.

Speaker1: [00:32:11] Yeah. And just thinking about that population in its entirety and really engaging well across the ecosystem of different providers, well beyond the NHS. That's how we will long-term, turn the dial on population health.

Speaker3: [00:32:27] Well, I hope you'll come back and share how the forward plan over the next few years is manifesting with that clarion call to policymakers. Thank you so much for your time today, Rima.

Speaker1: [00:32:39] Thank you very much.

Speaker3: [00:32:40] It's been a pleasure.

Speaker1: [00:32:41] Thank you.

Speaker3: [00:32:41] If you've enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to learn more about how we're turning the dial on the health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much and look forward to seeing you on the next episode.

Speaker2: [00:33:00] Voices of Care, the healthcare podcast.